ADVANCED PROSTATE CANCER:
PSMA THERAPY, PARP INHIBITORS & ROBOTIC SURGERY

Modern prostate cancer diagnosis has been transformed by multiparametric MRI (targeted biopsy replacing random systematic biopsy) and PSMA PET-CT (replacing conventional bone scan and CT for high-risk and recurrent disease). Genomic testing is now mandatory for all metastatic patients.

“PSMA PET-CT is 27% more accurate than conventional imaging in newly diagnosed high-risk prostate cancer — and changes management in 20–35% of patients. Being staged with bone scan and CT alone is no longer adequate.”

• Multiparametric MRI (mpMRI) + Targeted Biopsy

  PI-RADS 1–5 scoring guides targeted biopsy of suspicious lesions (PRECISION trial: more Grade Group ≥2 cancers detected, fewer Grade Group 1 over-detected). Standard at Chinese and Indian specialist urology centres. Provides pre-surgical neurovascular bundle mapping for nerve-sparing RALP planning. Cost: USD 300–800 in China/India vs USD 1,500–3,000 in USA.

• PSMA PET-CT (Ga-68 or F-18)

  proPSMA trial: 27% more accurate than conventional imaging. Detects nodal mets not visible on CT, bone mets not visible on bone scan. Mandatory for high-risk/very high-risk localised staging, biochemical recurrence after RP/RT, and patient selection for Lu-177-PSMA therapy. Cost: USD 800–1,500 China; USD 600–1,200 India (vs USD 3,000–6,000 USA).

• Germline + Somatic Genomic Testing (HRR, MSI, TMB)

  Germline BRCA1/2 + HRR panel (blood/saliva): recommended for all metastatic prostate cancer. BRCA2 present in 12–13% of mCRPC — most aggressive subtype; strongest PARP inhibitor sensitivity. Somatic tumor NGS or ctDNA liquid biopsy: mandatory for all mCRPC before second-line treatment. MSI/TMB testing for pembrolizumab eligibility. Cost: USD 800–1,800 in China/India.

• The Late Presentation Problem in Asia

  50–70% of prostate cancer patients in India present with metastatic disease vs <5% in the USA (where PSA screening has operated for 30 years). No widespread PSA screening programmes in South Asia, Southeast Asia, or the Middle East means most CancerFax patients present with mHSPC or mCRPC requiring systemic therapy from the outset — making access to novel AR inhibitors, PARP inhibitors, and Lu-177-PSMA critical.

Risk group determines treatment intensity. Grade Group 1 (Gleason 6) is managed with active surveillance in most patients; Grade Group 4–5 (Gleason 8–10) requires aggressive multimodal treatment. PSMA PET-CT is mandatory before committing to a plan for high-risk or very high-risk disease.

Radical prostatectomy and radiation therapy are equivalent in cancer control for most risk groups. The choice depends on patient preference, anatomy, comorbidities, and surgeon volume. RALP has become the dominant surgical approach; SBRT (5 fractions) is the most efficient radiation option for low-intermediate risk.

• Robotic-Assisted Radical Prostatectomy (RALP)

  Da Vinci RALP: 3D magnified view + 7-degree articulating instruments for precise nerve-sparing dissection in the deep pelvis. Hospital stay 2–3 days vs 5–7 for open RP. Bilateral nerve-sparing: 50–70% potency recovery at 12–18 months; urinary continence 85–95% at 12 months at high-volume centres. Peking University First Hospital: 500+ RALPs/year — one of the world's largest programmes. Cost: USD 8,000–18,000 in China; USD 6,000–15,000 in India (vs USD 30,000–60,000 in USA).

• SBRT / SABR (5 Fractions Over 1–2 Weeks)

  PACE-B trial: SBRT equivalent to conventional EBRT for low-intermediate risk prostate cancer. Fiduciary markers or MRI-linac real-time tracking required. CyberKnife and MRI-Linac platforms available at Chinese and Indian specialist centres. Highly convenient — entire radiotherapy course in 5 visits. Cost: USD 6,000–12,000 China; USD 5,000–10,000 India (vs USD 20,000–40,000 USA).

• EBRT/IMRT + Hypofractionation

  IMRT/VMAT with IGRT: daily image guidance corrects prostate positional variation. CHHiP, PROFIT, HYPRO trials: moderate hypofractionation (4–5 weeks) equivalent to conventional fractionation. Standard at specialist RT centres in China (Peking University Cancer Hospital, Fudan Shanghai Cancer Center) and India (Tata Memorial, Apollo, AIIMS). Cost: USD 8,000–15,000 China; USD 6,000–12,000 India (vs USD 30,000–60,000 USA).

• Proton Beam Therapy (for Selected Cases)

  Bragg peak: no exit dose beyond target — theoretically reduces rectal/bladder dose vs photon IMRT. Preferred for patients with IBD, prior pelvic RT, or specific anatomy. Shanghai Proton and Heavy Ion Center: also offers carbon ion therapy with highest conformality and radiobiological advantage for high-grade radioresistant prostate cancer. India: Apollo Proton Cancer Centre Chennai (South Asia's first proton centre). Cost: USD 20,000–35,000 China; USD 15,000–28,000 India (vs USD 40,000–90,000 USA).

All three approved next-generation AR inhibitors for nmCRPC (PSA doubling time ≤10 months on ADT, no metastases on conventional imaging) improve metastasis-free survival and overall survival. Drug choice is based on tolerability profile and patient comorbidities.

ADT monotherapy is no longer adequate for most mHSPC patients fit for treatment intensification. Multiple Phase III trials establish doublet (ADT + one agent) and triplet (ADT + two agents) as the new standards, with triplet preferred for high-volume disease in fit patients.

Five mechanistically distinct drug classes improve survival in mCRPC. Sequencing is guided by prior treatment history (cross-resistance between AR inhibitors), biomarker profile (HRR mutations → PARP inhibitors; PSMA expression → Lu-177-PSMA), and disease characteristics.

20–25% of mCRPC patients carry HRR gene mutations. BRCA2 (12–13% of mCRPC) confers the strongest PARP inhibitor sensitivity. Germline + somatic NGS testing is mandatory before any PARP inhibitor consideration.

The VISION trial established Lu-177-PSMA-617 as the only systemic therapy to demonstrate OS benefit in heavily pretreated mCRPC since cabazitaxel. PSMAfore is extending the indication to earlier-line mCRPC.

Lu-177-PSMA therapy requires PSMA PET-CT eligibility confirmation, organ function assessment, and licensed nuclear medicine centre infrastructure. CancerFax manages the entire pathway for international patients.

1. 1

   Eligibility Review and Prior Treatment Confirmation

   CancerFax reviews full treatment history to confirm eligibility: prior ARPI (enzalutamide/abiraterone/darolutamide/apalutamide) and at least one taxane (for VISION indication) — or prior ARPI only for PSMAfore expanded indication. ECOG PS 0–2 required. Adequate haematological, renal, and hepatic function thresholds confirmed.

2. 2

   PSMA PET-CT Imaging — Eligibility Confirmation

   Ga-68 PSMA-11 or F-18 DCFPyL PET/CT confirms: (1) PSMA-positive disease at all metastatic sites visible on conventional imaging; (2) no dominant PSMA-negative lesions (which would escape treatment and indicate clonal heterogeneity). FDG-PET also reviewed if available to identify discordant PSMA-negative / FDG-positive lesions. CancerFax facilitates PSMA PET-CT at partner centres in China (USD 800–1,500) and India (USD 600–1,200).

3. 3

   Treatment Centre Selection — China or India

   Centre matched based on patient preference, proximity, and available infrastructure. China: Peking Union Medical College Hospital, Cancer Hospital CAMS, Fudan University Shanghai Cancer Center, Sun Yat-sen University Cancer Center. India: Tata Memorial Centre Mumbai, Apollo Proton Cancer Centre Chennai, AIIMS Delhi, major Bengaluru and Hyderabad centres. All centres licensed for therapeutic radionuclide use.

4. 4

   Treatment Cycle Administration (Up to 6 Cycles, Every 6 Weeks)

   Lu-177-PSMA-617 administered intravenously at the nuclear medicine facility. Each cycle takes approximately 2–4 hours including monitoring. Radiation precautions required for 48–72 hours after each cycle (separate toilet, limited close contact with children/pregnant women). Blood count and renal function checked before each cycle.

5. 5

   Post-Treatment Response Assessment

   PSA response assessed at cycle 2 and after cycle 4. Repeat PSMA PET-CT after 3–4 cycles to assess disease response and PSMA expression persistence. Haematological monitoring (anaemia, thrombocytopenia) and renal function tracked throughout. Post-programme follow-up coordinated with home oncologist via CancerFax telemedicine framework.

China and India have complementary strengths in advanced prostate cancer. CancerFax routes based on clinical need, required procedure, and patient geography.

China and India offer treatment at 70–90% lower cost than the USA. Generic AR inhibitors in India and China represent the most cost-accessible hormonal therapy globally. Lu-177-PSMA in India is the most affordable commercially available programme in the world.

Frequently Asked Questions